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About this, SG (neverminding your inability to even FIND, much less read, and MUCH MUCH less understand actual original research)

This?

At some point, even if it's not true, you're better off just saying you "mis-spoke" or something like that.

And yet you continue to argue against my posts saying it was sometimes useful to give Tamiflu even if initiated longer that 48 hours.

Both my comments were correct in context. Between 24 and 48 hours the benefit is minimal. A patient calls you on the phone, the kids have flu symptoms during a community flu outbreak and are otherwise doing OK. Would you really tell that parent to haul their kid down to the clinic to get an expensive med that at most was now going to shave a day off the symptoms?

[snipped nonsense not helping the discussion]( your contention that there is nothing confusing to the initiated not withstanding). And flu/winter respiratory illness and deaths have a HUGE "unknown" factor (or series of "known unknown" factors).

I do contend there is NOT a HUGE unknown factor when you look at all the influenza surveillance databases.

Originally Posted by kellyb

I can cherry-pick seasons that show that RSV is the driving force behind the highest peaks in P&I, too.

I actually started to make a spreadsheet with images and everything, before realizing I would only be arguing with you, and [b][snipped unhelpful nonsense]

By all means, show us some RSV peaks based on virology labs reports on patient cultures ordered by physicians that correlate with epidemic rates of ILIs and P&I mortality.

There are 5,000+ thread views, I wouldn't be investing so much time in this thread if I thought people posting were the only people reading the thread.

But while you're at it with your spreadsheets, try to find the actual number of documented RSV fatalities. I've posted a number of studies with culture confirmed influenza hospitalizations and fatalities. You posted a link showing some ARIs in the elderly that require medical care are RSV.

Are you claiming RSV mortality is as significant as influenza mortality and somehow the majority of researchers and providers in the medical community are oblivious to this? They're so duped by Big Pharma and confirmation bias that all their efforts to address influenza are based on ignorance of RSV? And you have seen it when no one else has?

Originally Posted by kellyb

Have fun in that self-prescribed ghetto, arguing with with your own robo-ilk, mooching opinions from the US-only CDC/ACIP consensus, and dissing the consensus of almost every other public health authority on planet Earth.

Very telling. I think we are getting to the bottom of at least part of this.

__________________(*Tired of continuing to hear the "Democrat Party" repeatedly I've decided to adopt the name, Pubbie Party, Repubs "Republics" and Republic Party in response.)

According to figure 1, labs in the north and south regions peaked earlier while an equal peak occurred later in the west and midwest regions. If RSV represented a large proportion of the P&I mortality, you would then expect to see two peaks in P&I deaths. If RSV accounted for the large spike in P&I deaths, you would expect any year with a similarly high peak in RSV cultures to produce an equally high peak in P&I. But you do not see that in other years with relatively high RSV rates.

Not necessarily given the different regional baselines and gaps in geograpical surveillance coverage. We also don't know what contribution RSV is actually making to P&I mortality since again, we have numerous co-circulating pathogens. Check out some other years, you may have already and see that they don't neatly align with your beliefs.

Quote:

As for what did I mean by: "It's not just the numerical nature of the denominators, it's the sample they are drawn from", I'll give you an example.

If you take a population at high risk of a disease, then tests on that population will give much different results than you'd get in a population at low risk. It's not just total numbers, it's also proportions that are going to differ.

I noted the biggest problem trying to match RSV data to P&I and ILIs, the RSV cultures are not coming from a random sample of people with ILIs, and in fact, you would expect more RSV in the lab data because all seriously ill infants with an ARI are going to get an RSV culture. You need it to guide treatment. This is not true for all seriously ill adults with an ARI.

RSV samples go through the same surveillance network as influenza and a number of other respiratory pathogens. You don't even know the burden of RSV in adults and clearly emerging as a pathogen of interest in the elderly so really what is your point other than, "ooh look that way"?

Quote:

More importantly, RSV doesn't account for surpassing epidemic thresholds for P&I, instead, RSV is part of the baseline winter P&I burden.

This is getting really boring. You really don't know what you are talking about. Have a read:

Quote:

The percentage of patient visits to healthcare providers for ILI reported each week is weighted on the basis of state population. This percentage is compared each week with the national baseline of 2.2%. The baseline is developed by calculating the mean percentage of patient visits for ILI during non-influenza weeks for the previous three seasons and adding two standard deviations. A non-influenza week is defined as periods of two or more consecutive weeks in which each week accounted for less than 2% of the season’s total number of specimens that tested positive for influenza. Due to wide variability in regional level data, it is not appropriate to apply the national baseline to regional data; therefore, region specific baselines are calculated using the same methodology.

Did you get the part about non-influenza weeks? Do you think that there might be other respiratory pathogens that have the same seasonality?And furthermore:

Quote:

Does CDC think that influenza causes most P&I deaths?

No, only a small proportion of deaths in either of these two categories are estimated to be influenza-related. CDC estimated that only 8.5% of all pneumonia and influenza deaths and only 2.1% of all respiratory and circulatory deaths were influenza-related.

And even though you quoted this before, it doesn't seem to have affected your adherence to error-prone estimations:

Quote:

Pneumonia and Influenza Mortality: The percentage of P&I deaths exceeded the epidemic threshold for 31 of 33 weeks during the 1999-2000 influenza season and peaked at 11.2% during mid-January. Whether the higher-than-expected percentage of P&I deaths was due to influenza activity, respiratory illness due to some other pathogen, or reporting changes in the 122 Cities Mortality Reporting System is unknown. Because of changes in the reporting case definition that occurred just prior to the start of the 1999-2000 season, the current increase in P&I mortality should be interpreted with caution.

And yet you continue to argue against my posts saying it was sometimes useful to give Tamiflu even if initiated longer that 48 hours.

But you didn't say that: "If onset is past the initial 24 hours, antivirals like Tamiflu are not useful."

Quote:

Both my comments were correct in context. Between 24 and 48 hours the benefit is minimal. A patient calls you on the phone, the kids have flu symptoms during a community flu outbreak and are otherwise doing OK. Would you really tell that parent to haul their kid down to the clinic to get an expensive med that at most was now going to shave a day off the symptoms?

There posted again, there is no mistaking you said it wasn't useful past 24 hours, not 24-48 hours and not all the wishful-thinking can change that.

But go ahead, continue this sidetrack if it makes you happy. I'll move back on to the thread topic.

Oh you mean the topic that's supposed to be about the Cochrane influenza vaccine reviews? Would you please do that? Frankly it would be in your best interest to do so considering your grasp of flu epidemiology. And honestly, I have lost interest unless you can manage to discuss what you allegedly started this thread about.

First, let's be clear, I'm not saying RSV isn't an important pathogen and when we only look at pediatric deaths, it has a much higher mortality rate than influenza. I also don't want to be misunderstood, I have said repeatedly all ILIs and all P&I mortality are not influenza.

If, after all, flu cultures are positive only in 10-50% of sampled sentinel ILIs from year to year, there's a whole lot of other respiratory pathogens out there besides influenza. No one has said otherwise. That fact keeps getting muddled here when ILI and P&I numbers are conflated with influenza burden.

When I'm referring to influenza burden, I'm referring to the numbers that are derived from models that use MULTIPLE DATA SETS.

One question is, when P&I mortality and ILI rates exceed the seasonally adjusted epidemic thresholds, do they reflect influenza morbidity and mortality? Well for one, when the epidemic threshold excess is blamed on influenza, THE % OF INFLUENZA SHOWING UP IN SENTINEL SAMPLES INDICATES THAT IS THE CASE. The claim no one is actually testing these patients is simply false.

The total numbers of estimated influenza burden are based on the ILI and P&I rates plus a number of other factors including culture positive rates of the sentinel samples and hospitalized patients. Claiming, as Jefferson reportedly did, that no one has done these cultures just isn't true.

In addition, the increased use of in-clinic flu screening tests has not shown any evidence flu is not causing the disease burden during identified influenza epidemics.

Despite the fact RSV is a serious disease in children and the elderly, that doesn't make the influenza burden models wrong, because ILIs and P&I rates are not the only thing the models look at.

But let's look more closely:

I found one source that compares RSV to influenza. Is influenza being overestimated due to underestimation of RSV?

RSV was associated with an annual mean of 11,321 deaths; this number did not vary much from year to year. “When you look at circulation patterns,” said William W. Thompson, PhD, an epidemiologist with the Immunization Safety Branch of the National Immunization Program at the CDC, “RSV has a clear seasonal pattern. It’s predictable—much more so than influenza.”

If you look at table 1, you see why RSV mortality can be high but accounts for a smaller number of total deaths even considering many of those deaths are in the elderly. RSV mortality proportions are higher than flu in infants, but lower than influenza in the elderly. The elderly account for more deaths, flu kills more total people than RSV.

There is a comment in the discussion that some flu in the elderly might be assumed flu and that would miss other pathogens like RSV.

Quote:

“RSV is hard to detect in the elderly, because it’s more difficult to isolate the virus,” said Dr. Thompson. “Generally speaking,” he continued, “in an elderly person, influenza is generally assumed instead of RSV.”

Just what Kelly and Este have been saying, RSV has a very high morbidity. Something I'm certainly not denying. But what about flu burden models? Does this make the flu estimate wrong? Nope.

When you look at table 1 RSV accounts for more cases in the sampled specimens (9,000 vs 18,000). But when you look at table 5, influenza accounts for more total fatalities in both the respiratory and the cardiovascular categories (20 per 100,000 person years vs 7).

Quote:

The influenza and RSV model confirmed that influenza A(H3N2) viruses were associated with the highest attributable mortality rates, followed by RSV, influenza B, and influenza A(H1N1) viruses.

This study is 10 years old. In other words, it's nothing new. Do people really think the CDC has their head in the sand and their nose in a Big Pharma ring? Only the anti-vaxers know the truth and the medical community is duped?

If the medical community is so duped, I suppose Big Pharma won't push their case until they have a viable RSV vaccine.

Quote:

... In this study, RSV was the most common viral cause of death in children younger than 5 years, particularly in children younger than 1 year. However, RSV-associated mortality rates were higher in elderly persons and substantially more RSV-associated deaths occurred among elderly persons than among young children.Although the importance of RSV among young children is well recognized,41- 42 we found that more than 78% of RSV-associated underlying respiratory and circulatory deaths occured among persons aged 65 years or older. This finding highlights the need for an effective RSV vaccine in both young children and elderly persons.12,16,18,43

That study also corroborates what the other link noted:

Quote:

The annual effect of RSV on mortality was relatively stable, although the numbers of deaths associated with influenza viruses varied substantially, depending on the predominant circulating virus type or subtype.

In other words, the rates of RSV are accounted for in the seasonal epidemic threshold that rises in the winter. When the usual respiratory disease burden exceeds the epidemic threshold, and when sentinel samples are showing an increase in flu proportions, the epidemiology model of flu burden rightly includes that data.

And the more important thing as far as the thread topic, what's wrong with Dr Jefferson? What is he basing his 'flu is over-rated' position on? I have not found his claims to be substantiated. And that's weird. The flu burden is not being overestimated and the models are reliable.

__________________(*Tired of continuing to hear the "Democrat Party" repeatedly I've decided to adopt the name, Pubbie Party, Repubs "Republics" and Republic Party in response.)

The percentage of respiratory swabs that tested positive for flu dropped last week to 23.3% from 25.5%.

The CDC received reports of 14 more pediatric deaths, though 11 of them occurred in earlier weeks. Seven of the deaths were from influenza B, four were from an undetermined influenza A type, and three were linked to H3N2. So far this season 59 pediatric flu deaths have been reported.

The rate of hospitalization for lab-confirmed flu, however, increased from 25.9 to 29.8 per 100,000 population last week. The most affected group is still people age 65 or older, which accounted for more than 50% of the reported cases.

Mexico reported that 32.7% of respiratory swabs tested positive for flu, with influenza A responsible for the majority of cases and H3N2 predominating among subtyped viruses.

Overall the percentage of respiratory samples in Europe that tested positive for flu last week was 55%, a level that has risen progressively over the past 3 weeks, according to the ECDC....

ILI and P&I mortality rates correlate with flu outbreaks and serve to tell us if local flu activity is high or not, increasing or decreasing. It's winter. We already know RSV cases are up.

Quote:

Indicators for serious illness presented a mixed picture. The overall percentage of deaths from flu and pneumonia, while still markedly above the epidemic threshold, dropped from 9.4% to 9.0% last week.

Elsewhere in North America, flu indicators in Canada have also decreased, though doctors' visits for ILI are still running above expected levels for this time of year, according to a Feb 5 update on respiratory virus activity from the Pan American Health Organization (PAHO).

Belgium, Germany, Luxembourg, and Sweden reported high-intensity transmission. Increasing trends were reported by 22 countries and the United Kingdom. The countries that saw a resurgence of ILI after appearing to peak include Denmark, Greece, Ireland, and Luxembourg.

__________________(*Tired of continuing to hear the "Democrat Party" repeatedly I've decided to adopt the name, Pubbie Party, Repubs "Republics" and Republic Party in response.)

So, on camera Goldacre reverted to an answer about the Cochrane review of Tamiflu and said he knew Jefferson and thought Jefferson was an alright guy.

Off camera we had a longer discussion. He said, yes, researchers including those at the Cochrane Review, welcome to the real world, were full of biases. He was only acquainted with Jefferson, he wasn't that familiar with him.

Vaccines were not Goldacre's thing. But he wondered if maybe Jefferson's comment on the percent of ILIs that were culture + flu were taken out of context. Jefferson could have been referring only to the Tamiflu studies where ILIs were not carefully identified by culture as influenza in all the RCTs.

Goldacre was also aware of Doshi's work.

Goldacre's bottom line, even Cochrane Reviews were not above bias.

On a JREF personal note, Goldacre knew Phil Plait but was not familiar with the Bad Medicine Blog our local cadre of skeptical physicians were writing. I hope my comments will lead him to look at the bad med blog.

It was a great fun night. Glad I went.

__________________(*Tired of continuing to hear the "Democrat Party" repeatedly I've decided to adopt the name, Pubbie Party, Repubs "Republics" and Republic Party in response.)

So, on camera Goldacre reverted to an answer about the Cochrane review of Tamiflu and said he knew Jefferson and thought Jefferson was an alright guy.

Off camera we had a longer discussion. He said, yes, researchers including those at the Cochrane Review, welcome to the real world, were full of biases. He was only acquainted with Jefferson, he wasn't that familiar with him.

Of course researchers have biases, we all do. What matters is if personal biases affect the work.

Quote:

Goldacre was also aware of Doshi's work.

OK, but nothing critical to say?

Quote:

Goldacre's bottom line, even Cochrane Reviews were not above bias.

Did Dr. Goldacre actually say that Cochrane Reviews were not above bias or did you extrapolate that from his comment that researchers were not above bias? And more importantly, where are the biases in the flu vaccine reviews? You have yet to identify any.

Quote:

It was a great fun night. Glad I went.

I'm glad you did too; Dr. Goldacre is a good speaker, interesting topics, very animated and passionate even if he is often a fast-talker.

...Did Dr. Goldacre actually say that Cochrane Reviews were not above bias or did you extrapolate that from his comment that researchers were not above bias?

He said, vaccines weren't his thing. I steered the conversation to Jefferson's bias and yes, he very specifically said Cochrane Reviews were not above bias, and even talked about specific cases. He said criticisms of Cochrane Reviews were how they improve and discussing the concerns was how it happened. He encouraged me to contact them.

The Cochrane Library has a unique feature wherein users can post feedback on published Cochrane reviews. The Feedback Editor screens the feedback and in some cases, asks the authors to integrate this into the reviews. For further information regarding the feedback process, refer to the Cochrane Handbook for Systematic Reviews of Interventions and the Cochrane Policy Manual or email us at cochrane@ctc.usyd.edu.au

Major problems were identified in 15 reviews (29%). The evidence did not fully support the conclusion in nine reviews (17%), the conduct or reporting was unsatisfactory in 12 reviews (23%), and stylistic problems were identified in 12 reviews (23%). The problematic conclusions all gave too favourable a picture of the experimental intervention.

While evidence-based medicine is absolutely essential to comprehensive healthcare reform, it has been profoundly corrupted by money....

The Cochrane peer reviewers (at least 4 out of 7 of which had undisclosed financial ties to the drug companies that make anticoagulants) delayed four years over releasing this review for publication. When the only 3 RCTs discovered showed no benefit and possible harm from anticoagulants, the editor and peer reviewers directed us to include 8 additional lines of evidence supporting anticoagulation from about 50 other studies in the medical literature. When my critique of those 8 lines of evidence showed that they were all faulty, the peer reviewers did not rebut a single point. Instead, the editor demanded that we delete the additional lines of evidence from the review, because they were not from RCTs.

These comments were quite surprising, but they explain a couple things. One, they explain Jefferson's cynicism that the flu vaccine and Tamiflu studies are heavily industry biased. I don't completely disagree with that.

But in trying to counter this serious problem of positive bias in medical research, it is possible to overcorrect. And Jefferson's downplaying of the morbidity and mortality of influenza is not coming from a Cochrane Review, it's coming from opinion. In addition, the specific complaints I noted in the plain summary of at least one flu vaccine benefit study still hold.

I plan to carefully write my specific concerns up, and send an email to the CRs. It will take a bit of time to do.

Originally Posted by Estellea

...And more importantly, where are the biases in the flu vaccine reviews? You have yet to identify any.

He mentioned Doshi, and was interested in hearing more about my issue of Jefferson's bias but didn't know anything specific about the issue off the cuff. I'm hoping to get more of Goldacre's opinion with an email exchange.

__________________(*Tired of continuing to hear the "Democrat Party" repeatedly I've decided to adopt the name, Pubbie Party, Repubs "Republics" and Republic Party in response.)

...Did Dr. Goldacre actually say that Cochrane Reviews were not above bias or did you extrapolate that from his comment that researchers were not above bias?

He said, vaccines weren't his thing. I steered the conversation to Jefferson's bias and yes, he very specifically said Cochrane Reviews were not above bias, and even talked about specific cases. He said criticisms of Cochrane Reviews were how they improve and discussing the concerns was how it happened. He encouraged me to contact them.

So still nothing with regards to the Cochrane Reviews concerning influenza vaccines and Tamiflu? Having such a policy of transparency is a positive measure that will undoubtedly improve quality of reviews so you should contact them with specific concerns. But, I still don't know what those concerns are in spite of you starting this thread as you have not mentioned a single methodological problem with any of Jefferson's reviews.

Quote:

His contribution has added tremendously to my OP question.

How so? That you got your own confirmation bias massaged by Dr. Goldacre expressing that Cochrane Reviews and reviewers were not above bias? Again I ask, how does it follow that the Jefferson reviews are biased?

Major problems were identified in 15 reviews (29%). The evidence did not fully support the conclusion in nine reviews (17%), the conduct or reporting was unsatisfactory in 12 reviews (23%), and stylistic problems were identified in 12 reviews (23%). The problematic conclusions all gave too favourable a picture of the experimental intervention.

Emphasis mine. That is usually how publication and study biases go now isn't it? How does that compare to the Jefferson et al. influenza vaccine and Tamiflu reviews who found reduced effectiveness, publication bias and missing data?

While evidence-based medicine is absolutely essential to comprehensive healthcare reform, it has been profoundly corrupted by money....

Quote:

The Cochrane peer reviewers (at least 4 out of 7 of which had undisclosed financial ties to the drug companies that make anticoagulants) delayed four years over releasing this review for publication. When the only 3 RCTs discovered showed no benefit and possible harm from anticoagulants, the editor and peer reviewers directed us to include 8 additional lines of evidence supporting anticoagulation from about 50 other studies in the medical literature. When my critique of those 8 lines of evidence showed that they were all faulty, the peer reviewers did not rebut a single point. Instead, the editor demanded that we delete the additional lines of evidence from the review, because they were not from RCTs.

These comments were quite surprising, but they explain a couple things. One, they explain Jefferson's cynicism that the flu vaccine and Tamiflu studies are heavily industry biased. I don't completely disagree with that.

So if you acknowledge that there are study biases and these are what Cochrane reviewers have to pick from, then how is it so difficult for you to accept that the reviews are correct in their conclusions?

Quote:

But in trying to counter this serious problem of positive bias in medical research, it is possible to overcorrect. And Jefferson's downplaying of the morbidity and mortality of influenza is not coming from a Cochrane Review, it's coming from opinion. In addition, the specific complaints I noted in the plain summary of at least one flu vaccine benefit study still hold.

Look, you still haven't done an iota of basic research here which is to examine the reviews' methods and critique them. In fact I still don't think you have read the reviews you are questioning. Please tell me, what specifically are the methodological problems with the influenza vaccine reviews that render them so unbelievable to you? If you can't answer that then what do you have to write to the Cochrane Collaboration about?

Quote:

I plan to carefully write my specific concerns up, and send an email to the CRs. It will take a bit of time to do.

So still nothing with regards to the Cochrane Reviews concerning influenza vaccines and Tamiflu? Having such a policy of transparency is a positive measure that will undoubtedly improve quality of reviews so you should contact them with specific concerns. But, I still don't know what those concerns are in spite of you starting this thread as you have not mentioned a single methodological problem with any of Jefferson's reviews.

Yes, I did. I noted discrepancies between the findings summary (a moderate effect on time loss) and the plain language summary (no effect on time loss). I noted the problem with comparing non meta-analysis data on vaccine side effects, and past analysis of vaccine research bias instead of looking at vaccine side effects and research bias in the data they were reviewing. And, the figure they used for vaccine side effects is not an average of all years, the GBS risk has been completely absent in many vaccine years.

Originally Posted by Estellea

How so? That you got your own confirmation bias massaged by Dr. Goldacre expressing that Cochrane Reviews and reviewers were not above bias? Again I ask, how does it follow that the Jefferson reviews are biased?

The OP asks, is the gold standard ever not so gold? We look at CRs as if they are infallible. I've answered my question, and supported the answer: CRs are indeed fallible.

To review what I said in the OP:

Quote:

From my perspective, when you have two discrepant data sources (lots of published research and several relevant Cochrane Reviews) it's wise to look for the reason for the discrepancy. It's not wise to assume the Reviews are superior because RCTs are the gold standard for medical research, or that the benefit only shows up because drug companies fund the studies

Now maybe the flu vaccine is all you and some others are interested in. My interest is also in assumptions that a CR is a superior source of research information.

I don't have a problem with the CR's conclusion the evidence supports flu vaccine is less effective than the figures being reported in the ACIP. I do object to the conclusion 60% effective is useless, and I'm pretty sure given the most recent information you'll see that new figure reflected in the ACIP flu vaccine guideline next flu season.

I do not find the CRs convincing where the conclusion is flu vaccine doesn't lower employee absenteeism. And I'm not convinced the argument is persuasive that vaccine is not useful as an adjunct to infection control measures. Until we have more data, there's no way to know

So still nothing with regards to the Cochrane Reviews concerning influenza vaccines and Tamiflu? Having such a policy of transparency is a positive measure that will undoubtedly improve quality of reviews so you should contact them with specific concerns. But, I still don't know what those concerns are in spite of you starting this thread as you have not mentioned a single methodological problem with any of Jefferson's reviews.

Yes, I did. I noted discrepancies between the findings summary (a moderate effect on time loss) and the plain language summary (no effect on time loss).

That's it? A measly, perceived discrepancy between the abstract and the plain language summary of a single phrase? You didn't read further in to say, Effects of interventions, Discussion, Characteristics of Studies? For those following along, I presume you mean Influenza Vaccines for Healthy Adults.

Quote:

I noted the problem with comparing non meta-analysis data on vaccine side effects, and past analysis of vaccine research bias instead of looking at vaccine side effects and research bias in the data they were reviewing. And, the figure they used for vaccine side effects is not an average of all years, the GBS risk has been completely absent in many vaccine years.

I'm sorry but what in Hades does the bolded even mean? The studies that included adverse events were discussed thoroughly as well as those not included. It isn't a figure for an average of all years, it's a figure for doses administered. You can't say the risk of GBS has been completely absent in many vaccine years because it hasn't even been examined most years. Thus, this is what we have to rely on and not wishful-thinking.

Quote:

Originally Posted by Estellea

How so? That you got your own confirmation bias massaged by Dr. Goldacre expressing that Cochrane Reviews and reviewers were not above bias? Again I ask, how does it follow that the Jefferson reviews are biased?

The OP asks, is the gold standard ever not so gold? We look at CRs as if they are infallible. I've answered my question, and supported the answer: CRs are indeed fallible.

Who is the 'we' that look at Cochrane Reviews as infallible? You have made the leap from an example of a review being biased (and I know it's more than that because I've read some) to the reviews on influenza vaccines and treatments are biased. How does one do that particularly when one hasn't even read the review in question? You are pretending that I don't notice this and that it's some kind of annoying observation and dodging it but it's central to your charge that the flu vaccine reviews are biased ergo wrong. You have offered zero evidence to support your assertion; you just keep repeating the assertion. It isn't going to come true you know.

Quote:

To review what I said in the OP:

Quote:

From my perspective, when you have two discrepant data sources (lots of published research and several relevant Cochrane Reviews) it's wise to look for the reason for the discrepancy. It's not wise to assume the Reviews are superior because RCTs are the gold standard for medical research, or that the benefit only shows up because drug companies fund the studies

Now maybe the flu vaccine is all you and some others are interested in. My interest is also in assumptions that a CR is a superior source of research information.

Once again I will point out that another meta-analysis by a completely different group found the same low vaccine effectiveness and study/publication biases. If you would like to find a better source of information that supports your claims, great; I'd love to see it and after seven pages, I don't know why you haven't produced any. Cochrane Reviews are the gold-standard but that doesn't mean we shut off critical-thinking when reading them; I don't know why you would assume this other than to build another strawman.

Quote:

I don't have a problem with the CR's conclusion the evidence supports flu vaccine is less effective than the figures being reported in the ACIP. I do object to the conclusion 60% effective is useless, and I'm pretty sure given the most recent information you'll see that new figure reflected in the ACIP flu vaccine guideline next flu season.

A.) Where in the review does it state that vaccine efficacy of 60% is useless? And
B.) Why do you insist on using the 60% figure as an across-the-board efficacy when it is pooled for a certain age group?
So what if ACIP uses more evidence-based effectiveness estimates now when policy that has been based on poor-quality data and opinion has already been set?

Quote:

I do not find the CRs convincing where the conclusion is flu vaccine doesn't lower employee absenteeism. And I'm not convinced the argument is persuasive that vaccine is not useful as an adjunct to infection control measures. Until we have more data, there's no way to know

OK so you don't like the conclusion. Would you like to explain why you don't find it convincing? Preferably something in the form of studies and not your repeated assertion.

You see evidence the reviews can indeed be biased and you ask, "how is it so difficult for you to accept that the reviews are correct in their conclusions?"

Oh FFS; I've actually read the reviews, all of the influenza vaccine reviews and don't see any questionable problems with the methods. You're trying to infer that because some reviews have been subject to reviewer bias that Jefferson et al.'s reviews must be biased. And even more sadly...

You haven't even read them.

And if that's redundant then I suggest you actually read the reviews you have stated are wrong instead of seven more pages of mental gymnastics, contortions and distractions.

I can never understand why some antivaxers and folk like Jefferson get so incandescent when trials of flu vaccine demonstrate it cannot prevent illnesses that are not flu.

What next? Will they get narked that Polio vaccine only prevents polio, and not MS and meningitis?

__________________"Reci bobu bob a popu pop." - Tanja
"Everything is physics. This does not mean that physics is everything." - Cuddles
"The entire practice of homeopathy can be substituted with the advice to "take two aspirins and call me in the morning." - Linda
"Homeopathy: I never knew there was so little in it." - BSM

I can never understand why some antivaxers and folk like Jefferson get so incandescent when trials of flu vaccine demonstrate it cannot prevent illnesses that are not flu.

What next? Will they get narked that Polio vaccine only prevents polio, and not MS and meningitis?

Deetee, Jefferson has said the opposite with regards to the CDC's use of reduction in all cause mortality attributed to influenza vaccination. He doesn't have any expectation that influenza vaccines can prevent anything other than influenza.

Deetee, Jefferson has said the opposite with regards to the CDC's use of reduction in all cause mortality attributed to influenza vaccination. He doesn't have any expectation that influenza vaccines can prevent anything other than influenza.

Este

So according to you, the CDC thinks flu vaccine prevents other infections? Seriously? That's your position?

Or is it you are unaware a relationship exists between influenza and other causes of death besides pneumonia?

__________________(*Tired of continuing to hear the "Democrat Party" repeatedly I've decided to adopt the name, Pubbie Party, Repubs "Republics" and Republic Party in response.)

Could you clarify precisely what you've been talking about in this thread when you've complained repeatedly that the CDC overestimates influenza morbidity and mortality because they monitor ILIs and P&I deaths? (Preferably in a short concise summary and without the personal insults.)

__________________(*Tired of continuing to hear the "Democrat Party" repeatedly I've decided to adopt the name, Pubbie Party, Repubs "Republics" and Republic Party in response.)

Could you clarify precisely what you've been talking about in this thread when you've complained repeatedly that the CDC overestimates influenza morbidity and mortality because they monitor ILIs and P&I deaths? (Preferably in a short concise summary and without the personal insults.)

She never said anything like that!

WTF, SG?

Can you locate even one single instance of Este saying anything like "the CDC overestimates influenza morbidity and mortality because they monitor ILIs and P&I deaths" ?

__________________The whole problem with the world is that fools and fanatics are always so certain of themselves, and wiser people so full of doubts ~ Bertrand Russell

I don't know what more clarification you need considering you quoted a rather simplistic statement of mine and I've posted numerous links to support that.

Quote:

Originally Posted by Skeptic Ginger
Could you clarify precisely what you've been talking about in this thread when you've complained repeatedly that the CDC overestimates influenza morbidity and mortality because they monitor ILIs and P&I deaths? (Preferably in a short concise summary and without the personal insults.)

Kelly is correct, neither she nor I made such a statement. The mere monitoring of ILIs and P&I mortalities doesn't contribute to overestimations of morbidity and mortality attributed to influenza.

.... The mere monitoring of ILIs and P&I mortalities doesn't contribute to overestimations of morbidity and mortality attributed to influenza.

Este

OK, then why dismiss everything I posted about sampling the ILIs from sentinel sites to obtain cultures for an accurate estimate of flu burden, and the use of complex epidemiology models that consider multiple data bases to calculate flu burden?

Just where/when do you believe the CDC is overestimating flu burden?

It was brought up that the hospital cultures showed more RSV than it appears is being considered. Yet when I showed how two different samples sources, (hospital patient cultures and randomly sampled ILIs from sentinel sites), were not comparable, that fact was naively* dismissed.

*naive: meaning something a person was not familiar with, having nothing whatsoever to do with stupidity or an insult.

Now if you can show that those two completely different data sets, (hospital patient cultures and randomly sampled ILIs from sentinel sites), are indeed directly comparable, I'd like to see it. You need to show that non-random hospital viral cultures are equally likely to be ordered on patients hospitalized for influenza as they are likely to be ordered on patients hospitalized with RSV.

But they are not. It's critically important to know if an infant with bronchiolitis has RSV. It's NOT necessary to do that same viral culture on an elderly patient with a respiratory infection. On the baby you HAVE TO order the culture. On the elder person you need to do a bacterial culture.

There are times you treat empirically, meaning based on symptoms and history, and there are times when you need a specific diagnostic test. This basic medical fact will give you many more RSV+ cultures in the hospital lab report. IT'S NOT A RANDOM SAMPLE which I know the two of you understand.

The ILI samples are much more random and represent a sample from a large batch of ILI cases.

__________________(*Tired of continuing to hear the "Democrat Party" repeatedly I've decided to adopt the name, Pubbie Party, Repubs "Republics" and Republic Party in response.)

More distraction? You weren't dismissed "naively", you were dismissed because you were wrong and given explanation. RSV and Influenza samples are collected from the same NREVSS surveillance sites. Neither are randomly collected as they are showing up at sentinel sites with an ILI or ARI. So your argument falls rather flat if you are basing it upon random ascertainment.

This is about Cochrane influenza vaccine reviews; read them and post your specific methodological discrepancies.

More distraction? You weren't dismissed "naively", you were dismissed because you were wrong and given explanation. RSV and Influenza samples are collected from the same NREVSS surveillance sites. Neither are randomly collected as they are showing up at sentinel sites with an ILI or ARI. So your argument falls rather flat if you are basing it upon random ascertainment.

This is about Cochrane influenza vaccine reviews; read them and post your specific methodological discrepancies.

Data are collected from collaborating university and community hospital laboratories, selected state and county public health laboratories, and commercial laboratories. These participating laboratories report virus antigen detections, isolations by culture and polymerase chain reaction (PCR) results on a weekly basis.

Influenza specimen information, also reported to NREVSS, is integrated with CDC Influenza Surveillance.

1. Viral Surveillance —Approximately 85 U.S. World Health Organization (WHO) Collaborating Laboratories and 60 National Respiratory and Enteric Virus Surveillance System (NREVSS) laboratories located throughout the United States participate in virologic surveillance for influenza. All state public health laboratories participate as U.S. WHO collaborating laboratories along with some city and county public health laboratories and some large tertiary care or academic medical centers.Most NREVSS laboratories participating in influenza surveillance are hospital laboratories. The U.S. WHO and NREVSS collaborating laboratories report the number of respiratory specimens tested and the number positive for influenza types A and B each week to CDC.

This is the key thing you are missing here, the NREVSS data base is from tests ordered by health care providers because patients need the tests as part of their health care.

Quote:

2. Outpatient Illness Surveillance —Information on patient visits to health care providers for influenza-like illness is collected through the U.S. Outpatient Influenza-like Illness Surveillance Network (ILINet). ILINet consists of more than 2,700 outpatient healthcare providers in all 50 states, the District of Columbia and the U.S. Virgin Islands reporting more than 30 million patient visits each year. Each week, approximately 1,800 outpatient healthcare providers around the country report data to CDC on the total number of patients seen and the number of those patients with influenza-like illness (ILI)

This is the data base that the influenza surveillance viral culture data is taken from. A semi-random sample of ILIs are cultured. These are not tests ordered because a patient needs a diagnostic test.

__________________(*Tired of continuing to hear the "Democrat Party" repeatedly I've decided to adopt the name, Pubbie Party, Repubs "Republics" and Republic Party in response.)

http://cid.oxfordjournals.org/conten...ppl_1/S75.full
I'm ignoring you because you don't want to acknowledge what I have posted already so here is another. If you can't see what is wrong with this (and I suggest you look at the supporting references), then I can't help you.

This is the data base that the influenza surveillance viral culture data is taken from. A semi-random sample of ILIs are cultured. These are not tests ordered because a patient needs a diagnostic test.

Um do you know the difference between a 'database' and a 'surveillance system or sentinel site'? Do you grasp that the samples that are collected in the NREVSS are all tested by the same participating labs and then the results sent to the appropriate sectors? It's all within the same network FFS.

Oh please do describe this now 'semi-random' protocol for collecting ILI samples.

If I sample cultures ordered by doctors on sick patients, that is a non-random sample.

If you culture random samples from a large data base of reported ILIs in a sentinel surveillance network, that is a semi-random sample. (it would be completely random if everyone in the country with an ILI went to a doctor in the sentinel network.)

You cannot then compare the proportion of RSV in the doctor-needs-a-culture data base to the percent of ILIs that are influenza in the ILI-sentinel data base.

I have repeatedly noted the key reason you cannot compare these two proportions. Very few patients in the hospital with flu need a doctor ordered flu culture. There are very limited times any doctor would order a viral culture on an adult patient with a respiratory infection.

OTOH, a viral culture for RSV is mandatory for an infant with bronchiolitis. You don't often order ribavirin based on empirical evidence. The drug has special risks.

And, they are not tested in the same labs, that's why I used red and blue font. Read it again.

Quote:

state public health laboratories participate as U.S. WHO collaborating laboratories along with some city and county public health laboratories and some large ....

That cannot possibly be referring to this:

Quote:

Most NREVSS laboratories participating in influenza surveillance are hospital laboratories.

__________________(*Tired of continuing to hear the "Democrat Party" repeatedly I've decided to adopt the name, Pubbie Party, Repubs "Republics" and Republic Party in response.)

If I sample cultures ordered by doctors on sick patients, that is a non-random sample.

If you culture random samples from a large data base of reported ILIs in a sentinel surveillance network, that is a semi-random sample. (it would be completely random if everyone in the country with an ILI went to a doctor in the sentinel network.)

First, you are not using 'random' in any statistical sense. People show up at a network facility with an ILI or ARI and are tested, those that aren't are a result of a calculated or even arbitrary decision by the practitioner. This is a passive surveillance system; they are not going out into the community and randomly sampling the population or even randomly sampling people showing up at a facility. Next, I don't know why you are carping about this other than your obsessive need to be right but subsequently compounding your mistakes.

Quote:

You cannot then compare the proportion of RSV in the doctor-needs-a-culture data base to the percent of ILIs that are influenza in the ILI-sentinel data base.

I have repeatedly noted the key reason you cannot compare these two proportions. Very few patients in the hospital with flu need a doctor ordered flu culture. There are very limited times any doctor would order a viral culture on an adult patient with a respiratory infection.

No kidding? You mean like Thompson et al. did? Perhaps you should write a letter to him and his group at the CDC to tell him that. I'm sure he'd appreciate it. It would also appear that the CDC recommends testing of hospitalised patients for influenza if it's suspected.

Quote:

OTOH, a viral culture for RSV is mandatory for an infant with bronchiolitis. You don't often order ribavirin based on empirical evidence. The drug has special risks.

No, that is not true. Perhaps an individual facility will have a policy as such but that is not mandatory at all.

Quote:

And, they are not tested in the same labs, that's why I used red and blue font. Read it again. That cannot possibly be referring to this:

Read your own links. The influenza surveillance system is comprised of two laboratory networks for viral surveillance, the WHO and NREVSS; the latter also collects and tests samples for respiratory syncytial virus (RSV), human parainfluenza viruses (HPIV), respiratory and enteric adenoviruses and rotavirus detection. All samples for influenza as well as the above are from the same participating labs in the NREVSS. Most are hospital labs but not all. How or why that is even an issue is beyond me.

First, you are not using 'random' in any statistical sense. People show up at a network facility with an ILI or ARI and are tested, those that aren't are a result of a calculated or even arbitrary decision by the practitioner.

Thus I said semi-random.

Bottom line, people with criteria defining an ILI are identified and a random sampling from that group is where the %+flu number comes from. Doctors are not ordering the labs in the course of diagnosing or treating the patients. If the site wasn't part of the influenza sentinel surveillance system, those cultures would not be done. Rapid flu screening in the office would be the test of choice.

Originally Posted by Estellea

No, that is not true. Perhaps an individual facility will have a policy as such but that is not mandatory at all.

Not being current on RSV treatment I was wrong to say, if an infant were hospitalized with bronchiolitis, it would be malpractice not to test for RSV. From the AAFP guidelines:

Quote:

One evidence-based practice guideline9 states that routine laboratory studies for RSV infection, including nasopharyngeal washing to determine the presence of the RSV antigen, are not indicated. However, the rate of serious bacterial infections concurrent with RSV infection in otherwise healthy infants is low (less than 2 percent), so using rapid-detection tests for RSV antigen in high-risk infants 60 days or younger may reduce the frequency of costly evaluations for sepsis.11 Chest radiography is not necessary in the absence of clinical findings or other diagnostic suspicions. Cultures of blood or urine for bacteria are not necessary in uncomplicated bronchiolitis cases.

ANTIVIRAL THERAPY
Routine use of ribavirin (Virazole) is not recommended (B recommendation).

Studies of ribavirin in patients with bronchiolitis have been inconsistent, and other antiviral therapies have been studied. Antiviral therapy for RSV bronchiolitis is controversial because of its marginal benefit, cumbersome delivery, potential risk to caregivers, and high cost. However, ribavirin may be considered in patients with severe RSV bronchiolitis or those at high risk of severe disease.

So the essential fact remains, you would never use ribavirin without confirming the diagnosis.That makes the NREVSS data even less random!

Approximately 85 U.S. World Health Organization (WHO) Collaborating Laboratories ... [NREVSS snipped because this is a separate system you seem to think is the same system as the ILI sampling] ... All state public health laboratories participate as U.S. WHO collaborating laboratories along with some city and county public health laboratories and some large tertiary care or academic medical centers.

Think this through:

Quote:

Most NREVSS laboratories participating in influenza surveillance are hospital laboratories.

That portion of the surveillance system consists of specimens we send to the lab to diagnose our patients.

If I order a lab test on a patient, certain results are reportable. The patient tests positive for HIV, the lab files a report with the health department. If I don't also report the result, the public health calls me on the phone and says, we have this report, we need more info on the patient.

With the NREVSS, lab data comes from participating labs report their results on TESTS ORDERED BY PROVIDERS. There's nothing random about it. There is no sampling involved.

Each week, sentinel physicians, university health centers, hospitals/medical centers and public health agencies across the state report "influenza-like illness" (ILI) to the national Centers for Disease Control and Prevention (CDC) and collect samples for virus strain identification.

New York influenza surveillance sentinels are part of a 1900-member,
nationwide network. Because influenza is not a reportable disease, the CDC
seeks weekly reports of influenza-like illness (fever of 100º and cough or
sore throat in the absence of a known cause) and 6 patient specimens from
volunteering healthcare providers. This information – combined with data
from hospitals, nursing homes, and laboratories – is used to monitor the
emergence and timing, location, and circulation of influenza viruses each
year from October through May.

That's 6 specimens from each enrolled clinic which amounts to a large cumulative total across all 50 states.

In addition to weekly reporting, volunteer sentinel providers send throat swabs from patients for laboratory testing (virologic confirmation and subtyping) at the Georgia Public Health Laboratory. Data and isolates are shared with CDC and help determine which influenza strains will be included in next year's influenza vaccine.

Hopefully you get the picture. ILIs are reported AND sampled. This is semi-random surveillance of the % of ILIs that are reported in the flu surveillance system.

It differs from the non-random lab reports on provider ordered tests on seriously ill patients.

Originally Posted by Estellea

Read your own links. The influenza surveillance system is comprised of two laboratory networks for viral surveillance, the WHO and NREVSS; the latter also collects and tests samples for respiratory syncytial virus (RSV), human parainfluenza viruses (HPIV), respiratory and enteric adenoviruses and rotavirus detection. All samples for influenza as well as the above are from the same participating labs in the NREVSS. Most are hospital labs but not all. How or why that is even an issue is beyond me.

Este

I'll keep trying. I think what you are getting wrong will dawn on you sooner or later because you aren't dumb. You just aren't as familiar with this stuff as you believe you are.

__________________(*Tired of continuing to hear the "Democrat Party" repeatedly I've decided to adopt the name, Pubbie Party, Repubs "Republics" and Republic Party in response.)

Bottom line, people with criteria defining an ILI are identified and a random sampling from that group is where the %+flu number comes from. Doctors are not ordering the labs in the course of diagnosing or treating the patients. If the site wasn't part of the influenza sentinel surveillance system, those cultures would not be done. Rapid flu screening in the office would be the test of choice.

It's not even semi-random; this is a passive system. It's true that the samples are mainly for epidemiological purposes but you fail to grasp that cultures aren't the only tests and other molecular assays are the tests of choice and can be done relatively rapidly. These can be used for diagnostic purposes but not necessary according to the CDC. I don't even know why this is even important especially when a good deal of those tests are also for other respiratory pathogen detection. I can't even tell why you are insisting that testing is randomised and why that is relevant.

Quote:

Not being current on RSV treatment I was wrong to say, if an infant were hospitalized with bronchiolitis, it would be malpractice not to test for RSV. From the AAFP guidelines:

However, I was still right on the concept. I knew ribavirin was risky, I just didn't know some patients hospitalized still weren't sick enough to warrant ribavirin. So the essential fact remains, you would never use ribavirin without confirming the diagnosis.That makes the NREVSS data even less random!

I fail to see how you make this connection and again, how is it even relevant.

Christ on a cracker. The NREVSS is part of the influenza surveillance system. And yes, there are additional surveillance partners that also collect viral specimens and ILI activity. Why is this important other than for you to insist that you can't 'draw comparisons' between RSV activity and influenza activity when you can. I showed you this.

Quote:

Think this through: That portion of the surveillance system consists of specimens we send to the lab to diagnose our patients.

If I order a lab test on a patient, certain results are reportable. The patient tests positive for HIV, the lab files a report with the health department. If I don't also report the result, the public health calls me on the phone and says, we have this report, we need more info on the patient.

With the NREVSS, lab data comes from participating labs report their results on TESTS ORDERED BY PROVIDERS. There's nothing random about it. There is no sampling involved.

Hopefully you get the picture. ILIs are reported AND sampled. This is semi-random surveillance of the % of ILIs that are reported in the flu surveillance system.

It differs from the non-random lab reports on provider ordered tests on seriously ill patients.

I'll keep trying. I think what you are getting wrong will dawn on you sooner or later because you aren't dumb. You just aren't as familiar with this stuff as you believe you are.

The only thing that has dawned on me is the absurdity of your latest tangent. You didn't even know about the construct of the multiple networks that comprise viral respiratory surveillance until Kellyb and I showed you. I also showed you how the networks are used to compare the mortality of influenza and RSV in Thompson et al. for just one example. It's just plain preposterous and only seems to serve as more distraction from your OP.